This form may be used to share your concern about a student and to refer a student to Counseling Services. Please send the completed form in a sealed envelope to: Kathleen Fuchs, Director of Counseling Services, Buchanan Kiewit Wellness Center (or SPC#3).

Student's Name:

Reason(s) for concern or referral:

Check all that apply:
I would appreciate a phone call from a Counseling Services staff member to discuss my concerns about the student. Extension:
I have discussed my concern with the student.
I have recommended to the student that s/he seek counseling.
If the student is seen at Counseling Services, and gives permission, I would appreciate being informed that s/he followed through on my referral.
Faculty/ Staff Name:

Date (MM/DD/YYYY):

For counseling staff members to receive information about students does not require students’ knowledge or permission. According to law and professional ethics, for counseling staff members to disclose any information about students (including whether they are clients) does require students’ knowledge and written permission. Students have the right to withhold permission for release of information or only give permission for the release of selected information about their situation.